{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,3]],"date-time":"2026-02-03T18:21:22Z","timestamp":1770142882921,"version":"3.49.0"},"reference-count":40,"publisher":"Wiley","issue":"2","license":[{"start":{"date-parts":[[2012,1,30]],"date-time":"2012-01-30T00:00:00Z","timestamp":1327881600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["accpjournals.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Pharmacotherapy"],"published-print":{"date-parts":[[2012,2]]},"abstract":"<jats:p>Palpable purpura resulting from cocaine and levamisole coingestion has been reported with increasing frequency over the last several years as distribution of this drug combination becomes more universal. Toxicity from ingestion of this dangerous combination is difficult to diagnose due to the multitude of possible clinical presentations, variety of possible adulterants, and elusive nature of levamisole given its short half\u2010life and limited availability of detection methods. Levamisole is a chemotherapeutic and immunomodulatory agent currently marketed as a veterinary anthelmintic. We describe the case of a 48\u2010year\u2010old woman admitted to our intensive care unit with a diagnosis of streptococcal toxic shock syndrome (<jats:styled-content style=\"fixed-case\">STSS<\/jats:styled-content>), confirmed from fluid taken from an elbow lesion that grew <jats:italic>Streptococcus pyogenes<\/jats:italic>. She was noted to have bullae of the elbow and diffuse purpura with necrotic centers covering a large portion of her body (trunk, legs, arms, back, toes, fingers, and tip of nose). On further evaluation, she was found to have ingested levamisole\u2010tainted cocaine. The patient's complications related to either cocaine and levamisole coingestion or <jats:styled-content style=\"fixed-case\">STSS<\/jats:styled-content> included thrombocytopenia, acute renal failure, and limb necrosis. Thrombocytopenia gradually improved upon treatment with prednisone, and acute renal failure improved with intravenous fluid resuscitation; however, she subsequently required several appendage amputations due to severe gangrene. Clinicians must have high suspicion for ingestion of this drug combination and request prompt testing of urine samples for levamisole if a patient who admits to illicit drug use presents with purpuric or necrotic skin lesions.<\/jats:p>","DOI":"10.1002\/phar.1012","type":"journal-article","created":{"date-parts":[[2012,9,5]],"date-time":"2012-09-05T03:54:54Z","timestamp":1346817294000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":20,"title":["Palpable Purpura Complicated by Streptococcal Toxic Shock Syndrome Resulting in Limb Necrosis and Amputation: A Case of Levamisole and Cocaine Coingestion"],"prefix":"10.1002","volume":"32","author":[{"given":"Craig W.","family":"Freyer","sequence":"first","affiliation":[{"name":"Department of Pharmacy Henry Ford Hospital Detroit Michigan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael","family":"Peters","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Henry Ford Hospital Detroit Michigan"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2012,1,30]]},"reference":[{"key":"e_1_2_5_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9343(83)90889-6"},{"key":"e_1_2_5_3_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM198612043152302"},{"key":"e_1_2_5_4_1","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.36.12.1602"},{"key":"e_1_2_5_5_1","doi-asserted-by":"publisher","DOI":"10.4065\/80.5.671"},{"key":"e_1_2_5_6_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10067-006-0327-x"},{"key":"e_1_2_5_7_1","doi-asserted-by":"publisher","DOI":"10.1038\/clpt.2010.156"},{"key":"e_1_2_5_8_1","unstructured":"Erowid Crew.Cocaine adulterated with levamisole on the rise: status as of September 2009. Available fromwww.erowid.org\/chemicals\/cocaine\/cocaine_article2.shtml. Accessed January 16 2011."},{"key":"e_1_2_5_9_1","unstructured":"Substance Abuse and Mental Health Services Administration.Nationwide public health alert issued concerning life\u2010threatening risk posed by cocaine laced with veterinary antiparasite drug: SAMHSA press release September 21 2009. Available fromhttp:\/\/www.samhsa.gov\/newsroom\/advisories\/090921vet5101.aspx. Accessed June 30 2011."},{"key":"e_1_2_5_10_1","doi-asserted-by":"publisher","DOI":"10.1046\/j.0307-6938.2001.00944.x"},{"key":"e_1_2_5_11_1","unstructured":"European Monitoring Centre for Drugs and Drug Addiction.Levamisole as a cocaine adulterant November 10 2010. Available fromhttp:\/\/www.emcdda.europa.eu\/online\/annual-report\/2010\/boxes\/p66. Accessed June 30 2011."},{"key":"e_1_2_5_12_1","volume-title":"Presented at the 2010 international congress of the European Association of Poisons Centres and Clinical Toxicologists","author":"Lynch KL","year":"2010"},{"key":"e_1_2_5_13_1","doi-asserted-by":"publisher","DOI":"10.1186\/1477-7517-6-30"},{"key":"e_1_2_5_14_1","doi-asserted-by":"publisher","DOI":"10.1093\/jat\/33.9.620"},{"key":"e_1_2_5_15_1","first-page":"1381","article-title":"Agranulocytosis associated with cocaine use: four states, March 2008\u2013November 2009","volume":"58","author":"Centers for Disease Control and Prevention","year":"2009","journal-title":"MMWR Morb Mortal Wkly Rep"},{"key":"e_1_2_5_16_1","volume-title":"Presented at the 2010 international congress of the European Association of Poisons Centres and Clinical Toxicologists","author":"Ward JA","year":"2010"},{"key":"e_1_2_5_17_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpba.2011.03.039"},{"key":"e_1_2_5_18_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0893-133X(98)00034-7"},{"key":"e_1_2_5_19_1","doi-asserted-by":"publisher","DOI":"10.1002\/bdd.2510070110"},{"key":"e_1_2_5_20_1","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-150-4-200902170-00102"},{"key":"e_1_2_5_21_1","doi-asserted-by":"publisher","DOI":"10.1002\/mpo.2950240409"},{"key":"e_1_2_5_22_1","first-page":"1721","article-title":"Adverse reactions to levamisole","volume":"62","author":"Symoens J","year":"1978","journal-title":"Cancer Treat Rep"},{"key":"e_1_2_5_23_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-0560.2010.01613.x"},{"key":"e_1_2_5_24_1","doi-asserted-by":"publisher","DOI":"10.1001\/archdermatol.2010.335"},{"key":"e_1_2_5_25_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jaad.2010.01.055"},{"key":"e_1_2_5_26_1","doi-asserted-by":"crossref","first-page":"2","DOI":"10.5070\/D33Q1500T8","article-title":"Retiform purpura: a new stigmata of illicit drug use?","volume":"17","author":"Geller L","year":"2011","journal-title":"Dermatol. 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